CASAA draft position statement on ecigs and children

CASAA is currently putting together analytic and position statements about several of the burning topics in the the current THR debate. Our plan is to create drafts, put them out for peer review and member comments, and then post the final official version. Below you will find the first of these, posted here for comments. We welcome peer review comments on the empirical and analytic sections from anyone with expertise, and comments on the position statement from any CASAA members. Suggestions are also welcome on the labeling of the sections (which we are not thrilled about) and what to even call these. Something along the lines of “position statement” is typical, but it also implies that it is purely opinion which, as you will see, is not the case — it is mostly scientific analysis. (As with any review, of course, we will probably not act on every suggestion, but we will definitely consider them all.)

We believe these statements will be useful for people who are involved in the growing number of local fights about e-cigarette regulation and are otherwise engaged in attempts to educate. To that end, we include a first section which is the sound-bite version of the material that follows. We think the longer versions will be useful background for more serious conversations. A lot of the analysis we are including is often talked about, but has not been usefully consolidated anywhere.

**DRAFT** CASAA analysis of and position statement about underage use of e-cigarettes

[This draft version is for review. It is not CASAA’s official position. The final version will be published soon.]

Soundbite version

Despite a lot of hype, the evidence shows that few minors are even trying e-cigarettes and few, if any, are actually using them. The CDC statistics that have been spun as “underage usage has doubled” actually only showed that the number of children who had ever taken one puff doubled, which is basically inevitable given the newness of the product. Moreover, it is clear that most of those trying e-cigarettes are already smokers, so the e-cigarettes may be playing the same harm reduction role for children that they do for adults, and there is no evidence at all to suggest that e-cigarettes are causing children to smoke. The reason that some people become worried about underage use is because they mistakenly think that e-cigarettes post similar risks to cigarettes. To the contrary, of all the indulgences that children could be engaging in, e-cigarettes are among the most benign, and thus are probably reducing total health risks.

Background

A huge amount concern has been expressed about people under the legal age for use of tobacco products (hereafter: children) using e-cigarettes. This is similar to historical attacks on other low-risk tobacco harm reduction (THR) products, specifically smokeless tobacco, though is rather more aggressive due to the relative novelty of the products. It is clear that most of this noise is pure political strategy by people using it to serve other agendas, looking for any excuse to restrict or ban adult access to any tobacco product. The claims are groundless, in that they are scientifically false as well as expressing concern about a non-issue.

These metrics clearly exaggerate the phenomenon. Perhaps that is intentional, though it might just be blind repetition of measures used for other drugs, but either way it is the wrong measure. A puff on a cigarette in the last 30 days is reasonably predictive that someone is a smoker, since the rate of daily smoking is about half that of “last 30 day” smoking and about a third of children who try one puff become daily smokers. One incident of taking meth or cocaine is troublesome, even if it is just one. But it seems likely that one puff on an e-cigarette is often just that: a smoker trying one once to see if it works for her, or kids at a party passing one around as a lark — a lark that happens to be substantially less hazardous than many other things many of them will do that night.

The most hyped claim from the CDC data, that “use” doubled between 2011 and 2012, referred to only the “one puff ever in your life” statistic, despite the fact that the CDC defined “use” as “one puff in 30 days.” Relative measures, like “double,” are often used in propaganda to hide the fact that the absolute numbers are unimpressive. Among high school students (some of whom are old enough to legally buy tobacco), the number who tried an e-cigarette in the last month was less than 3% and for middle school students it was 1%, though the numbers are often spun to imply that the larger figure also applies to the younger children. The number who made a regular practice of vaping is obviously smaller still, though CDC did not attempt to determine that.

The number who have tried an e-cigarette once is small compared to the number who smoke (i.e., actually do it as an ongoing practice, not merely those who have ever puffed a cigarette) [http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6245a2.htm] or have recently tried/used other drugs [http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/NationalFindings/NSDUHresults2012.htm]. Indeed, the largest number in the e-cigarette results — that 10% of high school students had ever tried at least one puff (compared to less than 3% of middle school students) — is small compared to the number who have used other drugs in the last month: About 15% of high school students and 7% of middle school students have smoked in the last month; about 20% of high school students and several percent of middle school students have drunk alcohol in the last month; for illicit drugs the estimate for all children is in the range of 10%.

The fact that the “ever tried” statistics increased is not only unsurprising, but inevitable. E-cigarettes only entered the popular awareness and became widely available in the last few years. The only direction that “ever tried” could possibly go is up: if one child tried one puff on an e-cigarette in 2011 and one of his classmates did so in 2012, the prevalence of those who had ever tried a puff doubles (but notice that the incidence rate of trying did not increase at all and it might only represent two total puffs).

Perhaps most important, it is clear from the CDC data and further research [http://www.jahonline.org/article/S1054-139X%2813%2900748-9/abstract] that almost all of the children trying e-cigarettes are already smoking. In the e-cigarette report, the CDC only reported data for trying of cigarettes, as they did with e-cigarettes, and not all of those who had puffed a cigarette in the last 30 days are smokers, but smoking is likely to be an everyday practice for most of them and a frequent practice for many of the rest, in contrast with experimenting with a novel alternative. Thus, e-cigarette use among children seems to be playing the same role as it does for adults, harm reduction. But even if the harm reduction was unintentional or turned out not to be effective, it is still important to realize that most of those experimenting with e-cigarettes would have been smoking instead if the e-cigarette were not available.

A specific common claim, including by the CDC, is that children are trying e-cigarettes and this is causing them to become smokers when they would not have otherwise have done so (the standard anti-drug “gateway” story, which we address in a separate statement). There is no empirical evidence whatsoever that this is occurring. Indeed, we are not aware of a credible report of it having occurred even once (note that the mere fact that someone tried an e-cigarette before taking up smoking does not mean that e-cigarettes caused the smoking — you need to know a lot more to rule out the more likely possibility that the smoking would have occurred absent the e-cigarette).

Scientific analysis

Children experiment with drugs, sex, and other behaviors despite the wishes of many adults. Any children who are inclined to experiment have little difficulty acquiring cigarettes and alcohol, despite age prohibitions, as well as banned drugs, so it is inevitable that they can secure access to e-cigarettes and any other low-risk tobacco products. Thus, onerous restrictions on adult access to e-cigarettes cannot possibly be justified based on children’s use.

The implication of the rhetoric is that e-cigarettes are purely additive on top of other indulgences, though the reality is almost certainly that they are a substitute for not just cigarettes but other boundary-pushing behavior. Even if they are additive, it is difficult to see much reason for concern (apart from the speculative and non-credible gateway claims). If the above numbers were the trend in use of a drug that was as dangerous as alcohol, cigarettes, or many other drugs, then the trend might warrant alarm. But the health risk from e-cigarette use is trivial and it is increasingly clear that people who use them have a relatively easy time stopping if they so choose. If they are a substitute for cigarettes (as they appear to mostly be), or for other drugs like alcohol that pose serious physical threats or impair judgment and driving ability (the greatest threat to young people from all but the most rare and extreme drug behaviors), then the net effects are beneficial. Of all the ways to break the rules or engage in a bit of mild drug use, there are few that are more benign than e-cigarettes.

It is worth addressing, as an aside, the frequent claim that e-cigarettes facilitate vaping of cannabis and that this somehow poses a threat to children. The obvious responses to this are that while some pieces of expensive “mod” e-cigarettes can be used in rigs that can vaporize cannabis-containing oil, the cheap, widely-sold e-cigarettes cannot be repurposed in that way without substantial re-engineering. Moreover, there is the obvious absurdity of the implicit claim that a child who has secured access to a supplier of cannabis would somehow not have access to a device for consuming it were it not for e-cigarettes. It is obvious that the availability of e-cigarettes is not going to create any demand for cannabis.

The current empirical evidence is that children are not using e-cigarettes to any substantial degree. However, any honest and realistic projection of the future suggests this will change. E-cigarettes, their next-generation variants, and other THR products will inevitably become as widely used by, and as easily available to, adults as cigarettes, alcohol, and cannabis are now. Under those circumstances, we would expect that the same substantial portion of children who experiment with and use those other drugs will consider THR products. But because of the above analysis, this poses little reason for concern, and indeed some reason for hope that they will contribute to reducing harm.

Our position

Based on the above analysis, CASAA does not believe there is any reason for serious concern about children experimenting with e-cigarettes. Moreover, we believe that it is almost certainly the case that such experimentation has a net health benefit because it largely substitutes for harmful alternatives. However, we actively support prohibitions on sales of e-cigarettes to children and encourage merchants to voluntarily enforce such restrictions even when they are not required by law. We similarly do not object to regulations that make it more difficult for children to use e-cigarettes without creating a significant burden on adults, such as prohibiting possession in schools. (We generally object to criminalizing status offenses for children, but this is sufficiently tangential to our mission that we would likely never take an active role regarding such policies.)

We realize that if – as the evidence and science suggests – e-cigarettes are actually reducing children’s health risk from cigarettes and other drugs, such prohibitions are actually bad for the children. It is possible, however, that this problem will be somewhat self-correcting. Given the fact that children do find a way to get their hands on cigarettes and other forbidden products, those children who want to use e-cigarettes as a low-risk substitute for smoking will probably find some way to obtain them, just as they did for cigarettes. Moreover, the ban on underage use might make them more attractive to many children who might dismiss them if they were officially declared to be the legal alternative to smoking.

The main reason for supporting such bans is the political reality that they are important for protecting adult smokers’ access to e-cigarettes, which is the most important role for e-cigarettes. The specter of children using e-cigarettes is an effective strategy for those who want to prevent adult smokers from switching to low risk alternatives (and they know that, as evidenced by their active opposition to bans on sales of e-cigarettes to minors [http://antithrlies.com/2013/04/25/who-leads-the-fight-against-banning-e-cigarette-sales-to-minors/]). It is clearly unfortunate that such restrictions will cause some children who might have used e-cigarettes to smoke instead, but at least they would have legal access to a low-risk substitute when they reach majority. The current political climate means that intentionally denying children access to THR serves the greater good.

‘[W]e actively support prohibitions on sales of e-cigarettes to children and encourage merchants to voluntarily enforce such restrictions even when they are not required by law. We similarly do not object to regulations that make it more difficult for children to use e-cigarettes without creating a significant burden on adults, such as prohibiting possession in schools.’

This needs to be the very first thing you put in the position statement. It currently reads as a series of pleas about how harmless ecigs are – which will *not* wash with those who are on the fence; it seems too much like waffling.

As it stands now the takeaway message for people who aren’t interested in reading the wall of text will be, ‘Well, yeah, but not THAT many kids use them and they’re PROBABLY harmless.’

There seems to be some confusion about the purpose of this document. Part of that is caused by not knowing what to call it, though I did explicitly point out that it is not just an assertion of our attitudes, and the series needs a name that reflects that.

The first section is not an abstract or summary (nor is it an introduction). It is a few sentences that can be used to argue what we think are the key points about the topic to someone who who wants to formulate an opinion (or policy) about a complicated topic, but cannot be bothered to take five minutes to read a “wall” of 2000 words before doing so. It does not provide hooks to everything. In particular, this section does not include a summary of our normative position on the topic because we would not presume that a simple assertion of that really matters to anyone. I know that I basically ignore any statement in a paper that says “it is our position that…should…”.

The document is mostly a scientific analysis of a topic that generates pretty much all heat and no light in discussions. Those who do not care about our assertion of what we think is best should still find some value here. Basically, there is no where to go for such analysis, and so we are providing it.

Our opinion about details of optimal policy is the least important thing in the document. The takeaway message *is* the scientific observation that not many kids use them and they are probably actually protecting them from harm.

Mm. If it’s not meant to be a position statement, then it should not be called a position statement, because … it will be read as a position statement. Position statements are – I think anyway – statements of policy, not science-based analyses. You’d issue your position statement first, then go on to discuss the science-based reasons for that statement, I think.

If the *overall* intent is to provide a social and scientific analysis of ecigs, of which the discussion of their sales to minors is a part, you’re right that a broader topic title is called for.

For the series, perhaps something like ‘An analysis of the ramifications of ecigs on public health’? For individual sections, topical subheadings might be, ‘In regards to use of ecigs by minors’, ‘In regards to use of ecigs in the workplace’, ‘In regards to…’ etc. Maybe something a little less verbose and passive-voice, but does that make sense?

The title of the blog post was a bad choice — I agree. The draft title of the draft statement itself does lead with “analysis” before “position”, but is ugly awkward. Something along the lines of what you suggest seems like a better alternative.

Re editing, grammar, etc., maybe it’s worthwhile to consider sharing the text out as a Google doc for that kind of work? Theoretically you’d be able to track revisions, and accept/reject them as necessary…

There are quite a few run-on sentences and grammatical errors I’d have an English teacher go over it, or editor. Other than that, I mostly agree with everything said. I’ll have the Minnesota Vapers Advocacy’s Immediate Response Letters (IRL) team also look it over.

No doubt there are sentences that are longer than optimal, which a well-known hazard of letting me write the first draft of anything, and those should be shortened, but I would be surprised to learn of many grammatical errors; this was, after all, edited and re-edited for many days by a group of people who are good writers. Examples? Specifics?

Note: average sentence length in the previous paragraph is 20 words :-)

“Despite a lot of hype, the evidence shows that few minors are even trying e-cigarettes and few, if any, are actually using them.” (The words even and actually are not necessary, and again in the following sentence, and the word basically in the one after that.)

” Moreover, it is clear that most of those trying e-cigarettes are already smokers, so the e-cigarettes may be playing the same harm reduction role for children that they do for adults, and there is no evidence at all to suggest that e-cigarettes are causing children to smoke.” (Run on sentence, I suggest… “Moreover, it is clear that most of those trying e-cigarettes are already smokers. E-cigarettes may be playing the same harm reduction role for children that they do for adults. There is no evidence to suggest that e-cigarettes are causing children to smoke.”

Anyway, much of this continues through the article. I won’t tear the whole thing apart unless you wish me to I can e-mail you how I would revise it.

Moreover, the ban on underage use might make them more attractive to many children who might dismiss them if they were officially declared to be the legal alternative to smoking. I totally agree with this sentiment. Having two girls aged 18 and 22 I know first hand what usually happens when you outright “prohibit” them from trying something. They will do whatever they can to do just that. Having open talks about the risks carries more weight than simply saying “NO I forbid you”. Youth understand more than most people give them credit for.

This material could best be titled something like, ‘A Summary of the Evidence on E-Cigarette Use by Minors’. Using it as a Position Paper on CASAA’s view of youth and ecigs would be a disaster. Please get some political sensitivity; the science is close to irrelevant in politics.

Good title. But too cynical. I realize it might seem like science is irrelevant when you feel like a royal subject, living somewhere that they still put pictures of a hereditary monarch on the money and created a non-hereditary monarchy in Brussels to rule over you. But science does matter for policies like these in a lot of places. Of course, what matters most is how the science is interpreted, and the interpretation (spin) on this particular topic have been quite damaging, even though a correct interpretation would not be. Thus, the point of doing this. The nice thing about being on the side of truth is that the truth is usually on your side.

OK. Well, you guys have a Constitution that is routinely ignored; over here we live in a corruptocracy. Same difference :) All I’m saying is, please let’s tailor our media materials to the media / public / policymakers, not academia. Painful, but necessary. There is a space for ‘Policy Papers’, ‘Position Papers’, &c., as well as Evidence Reviews. We should probably have both.

The importance of the this dialog will be more beneficial when both sides of this single argument can agree that adults are the intended consumer with an actual potential for harm reduction from smoking and it’s associated behaviors. Until that time, there is far too much propoganda, hype science backed by beaurocratic fortresses towering over the lives of adults who wish to improve the quality of their lives by using e-cigarettes without the shameful stigma that smoking tobacco has.

I am not the the preferred choice of spokesperson by anyone not even by myself. That being said I have been seeking out those that I feel qualified and knowledgeable enough to take on this serious challenge facing smoker turned vapor….puffer, whatever. Dr Phillips I understood you to be the most knowledgeable experts in this field therefore I sought you out along with CASAA. I sought you out because I am adamant that the millions of smokers need to have the same opportunity as me. The same opportunity to have their mind opened long enough with truths and fact about the better alternative to smoking because it is safer for their health. I don’t wish for them to have to find out much too late like myself and have no choice or die. Artbylisabelle I noticed is the most sensible comment here. The rest is all about pleasing the very people against me and the other 5,999,999 other smokers who will pay the ultimate price for the lack of keeping it simple and to the point of facts. This has got to be accomplished before it is far to late. I hope you all understand my simple mission is to stress the importance of not getting sidetracked by manipulation of others. Thank you for listening.

A valid question. New stuff to write always gets in the way of finalizing old stuff. Very bad (common) habit. There are no plans to send it anywhere for now, but we should at least publish a final version, you are right (there have been some updates to it that are not published anywhere).

Tobacco Harm Reduction (THR)

THR is the public health strategy of encouraging smokers to switch to low-risk alternatives like smokeless tobacco and e-cigarettes. It is the only proven method for reducing smoking below about a fifth of the population once it becomes established. (So why would anyone be anti-THR? See the "About" page.)

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